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  • Measure Summary
  • NQMC:007418
  • Jan 2012

Foreign object retention: percentage of vaginal deliveries where a final count was conducted.

Institute for Clinical Systems Improvement (ICSI). Prevention of unintentionally retained foreign objects during vaginal deliveries. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 34 p. [24 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of vaginal deliveries where a final count was conducted.

Rationale

The priority aim addressed by this measure is to eliminate the number or rate of unintentionally retained foreign objects left following a vaginal delivery.

For as long as the medical community has been assisting women in performing vaginal deliveries, there has been the risk and misfortune of unintentionally retained foreign objects. Many measures have been instituted to mitigate the likelihood of an unintentionally retained item, but unfortunately they continue to occur.

Professional organizations such as The Joint Commission and Controlled Risk Insurance Company/Risk Management Foundation for Obstetrical Providers have developed guidelines for the prevention of retained items during vaginal deliveries. The Joint Commission categorizes the unintended retention of a foreign body after a vaginal delivery as a sentinel event. This categorization requires health care organizations to conduct a root cause analysis and to develop a corrective action plan designed to reduce the probability of a repeat occurrence.

Evidence for Rationale

Controlled Risk Insurance Company, Risk Management Foundation Clinical Guidelines For Obstetrical Providers. Prevention of retained sponges and needles following vaginal delivery. CRICO/RM. 2006;23:19.

Institute for Clinical Systems Improvement (ICSI). Prevention of unintentionally retained foreign objects during vaginal deliveries. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 34 p. [24 references]

Joint Commission International Center for Patient Safety. Reducing the risk of unintentionally retained foreign bodies. 2006.

Primary Health Components

Vaginal delivery; unintentionally retained foreign objects; baseline counts; final counts

Denominator Description

Number of vaginal deliveries with baseline counts done (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of vaginal deliveries where final counts were done

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence

Additional Information Supporting Need for the Measure

  • Per The Joint Commission's Sentinel Event Report dated June 2011, unintentionally retained foreign objects were the most frequently reviewed category in 2010 and through the first half of 2011. In 2010 there were 133 events reported, which is up from 119 in 2009. Through the first half of 2011, 76 events were reported which, when annualized, would exceed the 2010 rate by nearly 20 events.
  • In the first seven reporting periods (June 2003 to October 2010), the Minnesota Department of Health's Adverse Health Events Report showed 434 surgical events with 221 of those involving unintentionally retained foreign objects. In the most recent reporting period (October 2009 to October 2010), 34 unintentionally retained foreign objects were reported, three of which were sponges following vaginal delivery.

Evidence for Additional Information Supporting Need for the Measure

Institute for Clinical Systems Improvement (ICSI). Prevention of unintentionally retained foreign objects during vaginal deliveries. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 34 p. [24 references]

Minnesota Department of Health. Adverse health events in Minnesota: seventh annual public report. 2011 Jan.

The Joint Commission. Sentinel event report. 2011 Jun.

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Midwife

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

All ages

Target Population Gender

Female (only)

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Safety

Case Finding Period

The time frame pertaining to data collection is monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of vaginal deliveries* with baseline counts done

Population Definition: Patients of all ages who have a vaginal delivery.

Data Collection:

  • Determine the number of vaginal deliveries from unit logs or hospital billings. Out of that number, determine the number of deliveries that had baseline counts done. Then determine if the final counts were done for those deliveries.
  • This information can also be collected by random sampling of patient charts to determine whether final counts were done.
  • A sample size of 25 per month is recommended if collecting data through sampling. Can also look at the total number of vaginal deliveries. If less than 25 vaginal deliveries per month, use the total number of deliveries.

*Vaginal delivery includes labor and delivery and the end of the immediate recovery period (one to two hours) after vaginal delivery.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of vaginal deliveries where final counts were done

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of vaginal deliveries where a final count was conducted.

Measure Collection Name

Prevention of Unintentionally Retained Foreign Objects During Vaginal Deliveries

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Security Health Plan of Wisconsin, and UCare. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.

Composition of the Group that Developed the Measure

Work Group Members: Stephanie Doty, RN, MSN, MBA (Work Group Leader) (HealthPartners Regions Hospital) (Patient Safety & Quality); Kathleen Harder, PhD (University of Minnesota) (Human Factors Content Consultant); Carol Clark, RN, MSN (Fairview Health Services) (Nursing); Julie Thompson Larson, RN, BSN, MS (HealthPartners Regions Hospital) (Nursing); Cherida McCall, CNM (HealthPartners Medical Group) (Nurse Midwife); Douglas Creedon, MD, PhD (Mayo Clinic) (OB/GYN); Kari Retzer, RN (Institute for Clinical Systems Improvement) (Facilitator)

Financial Disclosures/Other Potential Conflicts of Interest

In the interest of full disclosure, the Institute for Clinical Systems Improvement (ICSI) has adopted a policy of revealing relationships work group members have with companies that sell products or services that are relevant to this protocol topic. It is not assumed that these financial interests will have an adverse impact on content. They are simply noted here to fully inform users of the protocol.

Stephanie Doty, RN, holds personal stock with 3M.

Doug Creedon, MD, is the treasurer for the Minnesota section of the American Congress of Obstetrics and Gynecology.

No other work group members have potential conflicts of interest to disclose.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2012 Jan

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Institute for Clinical Systems Improvement (ICSI). Prevention of unintentionally retained foreign objects during vaginal deliveries. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 34 p. [24 references]

Measure Availability

Source available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on January 16, 2013.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

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